198320114-8-14-2022-11-AS-EDAT-CHB3UL-20220814183340

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320114
Report Date: 08/14/2022
Date Signed: 08/14/2022 06:34:02 PM

Document Has Been Signed on 08/14/2022 06:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SUNCOAST SENIOR LIVING AT LONG BEACH		FACILITY NUMBER:	198320114
ADMINISTRATOR:	KIM, KI HWAN		FACILITY TYPE:	740
ADDRESS:	2520 GONDAR AVE		TELEPHONE:	(718) 683-1000
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 1	DATE:	08/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Ki Hwan Kim		TIME COMPLETED:	03:22 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/14/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Ki Hwan Kim and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for (1) hospice resident. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident's rooms, six (6) bathrooms, a living area, a dining area, a kitchen, and outside patio area. LPA toured the physical plant .All rooms were inspected. Beds and bedding supplies were in good condition, lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels stocked at the time of visit. Bathrooms were operational. The water temperature measured 118.6 F. A comfortable temperature of 74 degrees was maintained in the facility. LPA observed the facility to be furnished at the time of visit. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (2) fire extinguisher that is charged, smoke detectors operable. A working landline telephone remains available. INFECTION CONTROL: During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff tests and residents' vaccination were conducted. The facility has an approved Mitigation Plan Report on file with CCLD. Evaluation Report continues on LIC 809C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/14/2022 06:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNCOAST SENIOR LIVING AT LONG BEACH	FACILITY NUMBER: 198320114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation), the licensee did not comply with the section cited above. LPA identify bathroom for resident #1 is cluttered with wheelchair and chairs obstructing passage way. This violation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2022
	Plan of Correction
1 2 3 4	Licensee will adhere to the regulations 87307 will remove any items obstructing exits and passage ways. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/15/22

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation), the licensee did not comply with the section cited above. LPA identified (2) gallons of paint and cleaning solutions with bleach under sink and knives not stored in locked storage. This violation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2022
	Plan of Correction
1 2 3 4	Licensee will adhere to the regulations 87309 and stored toxic or hazidous items in lock storage. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/15/22

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/14/2022 06:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNCOAST SENIOR LIVING AT LONG BEACH	FACILITY NUMBER: 198320114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation), the licensee did not comply with the section cited above. LPA identified medication on top of refrigerator, bathroom and unlocked portabel refrigerator accessible to resident in care. This violation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2022
	Plan of Correction
1 2 3 4	Licensee will adhere to the regulations 8745 and store all medications in locked storage. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/15/22

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNCOAST SENIOR LIVING AT LONG BEACH	FACILITY NUMBER: 198320114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based observation, the licensee did not comply with the section cited above. LPA identified the entire facility cluttered and disarray. The kitchen counters not cleared with dirty dishes in sink. This voilation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/26/2022
	Plan of Correction
1 2 3 4	Licensee will adhere to the regulations 87303 and clear all rooms including the kitchen of clutter Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/26/22

Type B

Section Cited

CCR

87307(d)(2)

Personal Accommodations and Services

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA identified missing smoke detectors in room #1, #3, #4 and living room. R1's room missing a window covering. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/26/2022
	Plan of Correction
1 2 3 4	Licensee will adhere to the regulations 87307 and install missing smoke detectors and window covering for (R1)'s room. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/26/22

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/14/2022 06:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNCOAST SENIOR LIVING AT LONG BEACH	FACILITY NUMBER: 198320114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation) and (record review)], the licensee did not comply with the section cited above. LPA identified resident #1 (R1) had incomplete or missing service records for CCL to review. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/26/2022
	Plan of Correction
1 2 3 4	Licensee will adhere to the regulations 87506 will collect all required service records for resident #1. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/26/22

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNCOAST SENIOR LIVING AT LONG BEACH	FACILITY NUMBER: 198320114
	VISIT DATE: 08/14/2022

NARRATIVE

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DEFICIENCIES:
LPA observed entire facility disarray and clutter with miscellaneous items through the bedrooms, living room, kitchen, activity room and bathrooms. LPA identified kitchen with dirty dishes in sink and sharp knives in unlocked kitchen drawers. LPA identified smoke detectors not operable for rooms #1, #3, #4 and living room. LPA identified resident #1 (R1) did not have window covering for privacy. LPA identified (R1's) bathroom used for storage for wheelchairs and and other equipment devices obstructing passage ways. LPA unable to review service records for (R1) as the facility did not have the required LIC forms completed. LPA identified (2) gallons of paint and disinfectant and other toxic materials accessible to resident in care. LPA observed medications on bathroom basin and on top of portable refrigerator. A portable refrigerator that stores medication was unlocked.

Deficiencies are issued and an exit interview is conducted with Ki Hwan Kim. A copy of this report is provided along with the appeal rights.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2022

LIC809 (FAS) - (06/04)

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